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Midwife’s Guide to an Intact Perineum

An intact perineum is the goal of every birthing woman. We love to have whole, healthy female genitalia. Many people consider the health of the vagina/perineum to be a matter of chance, luck or being at the mercy of the circumstances of the forces that prevail at the time of the birth.

Folklore abounds about doing perineal massage prenatally. No other species of mammal does this. Advising a woman to do perineal massage in pregnancy implies a lack of confidence that her tissues have been designed perfectly to give birth to her infant.

The intact perineum begins long before the day of the birth. Sharing what the feeling of a baby’s head stretching the tissues will be like and warning the mother about the pitfalls in pushing will go a long way to having a smooth passage for both baby and mother.

The woman will be open and receptive to conversations in prenatal visits about the realities of the birth process. Here, in point form, is the information I convey for the second stage (pushing):

1. When you begin to feel like pushing it will be a bowel-movement-like feeling in your bum. We will not rush this part. You will tune in to your body and do the least bearing down possible. This will allow your body to suffuse hormones to your perineum and make it very stretchy by the time the baby’s head is stretching it.

2. The feeling in your bum will increase until it feels like you are splitting in two and it’s more than you can stand. This is normal and no one has ever split in two, so you won’t be the first. Because you have been educated that this is normal, you will relax and find this an interesting and weird experience. You may have the thought, “Gloria told me it would be like this and she was so right. I guess this has been going on since the beginning of humankind.”

“Red (or purple) Line that extends upwards between the bum cheeks”

3. The next distinct feeling is a burning, pins-and-needles feeling at the opening of the vagina. Many women describe this as a “ring of fire” all around the vaginal opening. It is instinctive to slap your hand down on the now-bulging vulva and try to control where the baby’s head is starting to emerge. This instinct should be followed. It seems to really help to have your own hands there. Sometimes women like to have very hot face cloths applied to their perineum at this point. If you like the feeling of this, say so, and if you don’t, say so. We will do whatever you feel like.

4. Most women like pushing more than dilating. When you’re pushing, you feel like you’re getting somewhere and that there really is a goal for your efforts.

5. This is a time of great concentration and focus for you. Extraneous conversation will not be allowed in the room. Everyone will be silent and respectful in between sensations while you regather your focus. Once you begin feeling the ring of fire, there is no need for hurry. You will be guided to push as you feel like until the baby is crowning (the biggest part of the back top of the head is visible). All that will be touching your tissues is the hot face cloth and your own hands. It is important for the practitioner to keep their hands off because the blood-filled tissues can be easily bruised and weakened by poking, external fingers. This can lead to tearing. We will use a plastic mirror and a flashlight to see what’s happening so we can guide you. We won’t touch you or the baby.

6. This point of full crowning is very intense and requires extreme focus on the burning—it is a safe, healthy feeling but unlike anything you have felt before. You may hear a devil woman inside your head who will say to you, “All you have to do is give one almighty push here and it will all be over—who cares if you tear . . . just give it hell and get that forehead off your butt!” This devil woman is not your friend. Thank her for sharing and then have your higher self say, “Just hang in there. It’s OK. Panting and rising above the pushing urge will help me stay together, and I will have less discomfort in the long run.” Your practitioner will be giving only positive commands at this point, and she will be keeping them as simple as possible to maintain your focus. Typically the birth attendant’s instructions are “Okay, Linda, easy . . . easy . . . easy . . . pant . . . pant with me . . . Hah . . . Hah . . . Hah . . . Hah . . . Hah . . . Hah. Good, that one’s over. You’re stretching beautifully; there’s lots of space for your baby. This baby’s the perfect size to come through.”

7. You will be offered plain water with a bendable straw throughout this phase because hydration seems to be important when pushing, and you can take the water or leave it, as you wish.

8. Once the head is fully born, you will feel a great sense of relief. You will keep focused for the next sensation, which will bring the baby’s shoulders out, and the baby’s whole body will quickly emerge after that with very little effort on your part. The baby will go up onto your bare skin immediately, and it is the most ecstatic feeling in the world to have that slippery, crawling, amazing little baby with you on the outside of your body. Your perineum may feel somewhat hot and tender in the first hour after birth, and believe it or not, the remedy that helps the most is to apply very hot, wet face cloths. This is in keeping with the Chinese medicine theory that cold should never be applied to new mothers or babies. Women report that they feel instantly more comfortable when heat is applied, and any swelling diminishes rapidly.

9. When you push your placenta out, the feeling will be like that of a large, soft tampon just plopping out. It is a good feeling to complete the entire process of birth with the emergence of the placenta.

When a new mother has an intact perineum, she recuperates faster and easier from birth. I like to twist a diagonally folded bath towel into a very tight roll and coil that into a ring for the woman to sit on when breastfeeding. Lovemaking can resume whenever the couple is ready; it feels good to use a little olive or almond oil as a lubricant the first few times.

26 thoughts on “Midwife’s Guide to an Intact Perineum”

O I love that.
You have condensed the best information and advice into a beautiful conversation Gloria, well done
Wish I had had you with me when I was listening to my own devil woman! (actually I prefer to think of her as my ‘mischievous monkey’ / Loki / Coyote woman).
Thanx very much for sharing this.

Yes!! i gave in to the devil woman! i suggest to women to roll 2 small towels or big hand-towels up and sit them parralell on the seat, which has a similar effect to the ring. they LOVE it (i know i did). i am really enjoying reading your blog Gloria, thak you.

Dear Gloria
i would like to have your confurmation to translate “Midwife’s Guide to an Intact Perineum” to hebrew and publish it on my website (with link and credentials of course) . pls let me know if it is ok with you?
Thank you so much
Ravit

THANK YOU for this post! I gave into that devil woman during my first labor, and tore both sides of my labia minora. My recovery was by far and away more tiresome and painful than my perfect nine and a half hour labor. Now 12 weeks along with baby number two, I am desperate to learn how to prevent tearing. Thank you for these tips!

Sometimes I think I must be very strange. With my first son, I was just coping with the contractions, and then all of a sudden my body started pushing – making these insane pushing noises and all. I just couldn’t control it at all. The doc checked me, and bub was crowning. I had no idea! How can you have a head in your vagina and not know!!

With both #1 and #2, I never felt the splitting in two sensation, the ring of fire, or pins and needles. I never felt the devil woman telling me ‘just get it out’. Is this odd to not experience this?

Also, with #2, I got him out with 3 contractions. First was to the eyebrows, second, the rest of the head, and third was the shoulders and the rest of the body. It was the shoulders that caused me to tear, not the head.

What can you do to avoid shoulder tears, rather than head tears? Or was this just a consequence of having a ‘daddy stitch’ with the episiotomy from #1’s birth?

GLOrious advice as always….I think that we really screwed up with so much emphasis on PREPARING the perineum, and as I used to ask when I started, “Why do we need the perineum brigade?Doesn’t it scare women into thinking if they don’t will explode if there are 4 hands there rather than 5?”

Great article, will be saving and rereading, I am due in 5 weeks time (give or take..hopefully take, as in taking time away…!) I do however practice prenatal perineal massage, and did with my first. I am aware it is anecdotal- it couldn’t really ever be anything else could it, as there are just too many factors to consider, you could never control for a myriad of factors and conclude it was/wasn’t helpful, but I don’t believe that it can’t be helpful because our tissues were made for birthing; they indeed are made for birthing, but also for healing and having the grand capacity to heal very well, and tearing as we know happens sometimes with the slowest, calmest births too, it is something every woman is frightened of but every woman accepts could happen, and doesn’t (in most cases) ruin her birthing experience (if not too severe). I also don’t feel it gives less confidence, for me, or implies that I am not made for birthing- it made the burning sensation feel familiar to me the first time around, and I felt helped me relax greatly during pushing, which was quite quick (around 20 mins) – I had not even a graze! I enjoyed my husband doing it, I liked the preparatory idea of it, and after all- we are often the only creature who does or doesn’t do things other mammals do during birth. I’m sure they don’t apply hot compresses either, but I agree that can feel helpful and supportive, I think perhaps many of the things we do are for the ‘feeling’ of being supported, and not ‘necessary’ – which is natural, for creatures that think and interact in the way we do. In my opinion, this mental support is as natural as a physical necessity.

I wonder if you have any advice when there is a nuchal arm involved in a birth. I know I pushed my first out too quickly ~ I did not have a supportive CNM (hospital birth due to 43 weeks, originally planned lay midwife birth center birth)… she was hands off but wanted me to purple push, I refused that, but was discouraged from moving into a gravity assisted position (was side lying)… and I was encouraged to push as hard as I could… I was told afterward that my son’s nuchal arm and size (last push brought all 10lbs of him out) were the reason for a rather severe 2nd degree vaginal wall tear. I would love to read your thoughts on how size and nuchal arms might affect the perineum… or if tears in such situations are more or less unavoidable. Thanks.

I had 5 tears that needed stitching inside my vagina from pushing my son out, it took 3 1/2 hours. The devil women was my doctor who encouraged me to push push push!
Wish I read this before I gave birth to my son. My daughter was an entirely different experience, I had a midwife and I pushed for 4 minutes! Truthfully I loved both my births but my 2nd was a piece of cake in comparison to my 1st.

So what about preparing for birth after a 4th degree tear the first time? I intend to massage Vit and EPO onto my perineum daily the next time I am pregnant. I do worry about the scar tissue interfering. (Oh, and I had that tear in a home, water birth. But that devil self as you call it was telling me to PUSH, while my primal self was telling me to PUFF, but the brain won out, sadly. My girl came out all in one push and we believe she had a nuchal arm.)

I had a bad third degree tear 1st time around in hospital following a non-consentual episiotomy which thanks to the ‘Butcher from Bombay’ (as I dubbed the ob/gyn). Despite 3 salt baths and 2 showers a day, the wound got infected and required more surgery at 6 weeks post partum (to remove scar tissue that was preventing the wound from closing) before it finally healed at 7 weeks. I bled every time I had a bowel movement for at least 6 months post partum and I have major and very unattractive scar tissue in that area as a result of my perineal tear.

I had my 2nd baby 10 years later at home in our spa. Perineal tearing was foremost in my mind, and I even considered a vaginal dilator device. In the end, I chose to go all natural and trust my body. I didn’t so much as massage that area.

I had a completely hands off Independent Midwife who just encouraged me to go with my body during my 2nd birth. I actually find the pushing stage of labour way more painful than the dilating stage (which was almost painless until right at the end), and had never felt the ‘ring of fire’ before thanks to an epidural that was pushed on me the 1st time around. I have a dodgy lower back, so pushing wasn’t much fun.

So I was keen to get my baby out ASAP. I pushed like a crazy woman during every contraction and the 2nd stage of labour only took an hour. I ended up with a minor 2nd degree tear (so only just into the muscle). My Midwife examined me and said she could put in a stitch or two if I liked but that the wound was sitting beautifully and was likely to heal well if left alone. After my infection experience 1st time around, I opted for no stitches.

The wound literally only stung the 1st evening when I urinated and by the next day, even when washing in the shower, the wound was not painful. My Midwife gave me a lovely homemade spray of witchhazel and some essential oils to spray on it after bathing each day and the wound was completely healed within a week.

So different to my 1st recovery which involved hobbling like a crippled woman (I looked worse than a C/S mama) and carrying around a blow up donut pillow every where I went. I had no discomfort sitting after my 2nd baby and felt fabulous.

I had a 4th degree tear with my first baby. Then I had 2 C-Sections because my doctors basically scared me into them because of the tear. #4 & #5 baby were VBA2C’s and I didn’t tear at all. My OB was great about letting the baby’s head do the stretching and he encouraged the intact perineum. I didn’t do anything ahead of time to prepare and was on cloud 9 that I didn’t tear. I know it’s scary to think you could tear again like that but really talk to your dr. about it and go in knowing what needs to happen to help you not tear. And trust your body. I talked to so many women who had 4th degree tears the first time and went on to have nothing more than a 2nd for subsequent births. Best of luck to you!

Thank you so much for this article. After being heavily coached at our first hospital birth and then with midwives who were otherwise wonderful, my husband and I need this advice and knowledge to move forward with our birthing plans for our third and final baby. We are striving for what you have mentioned in your writing – a birth with no regrets. Thank you for your site and all you share. You are instrumental to getting us there

Yes! I just had my first baby. He was 8lbs 10oz and I didn’t tear at all. I read Ina May’s guide to childbirth and tried to mentally prep myself for the ring of fire and kept telling myself my body was made for this and only the baby will come out and no one has ever split in two. I was in a hospital and the ld nurses kept trying to coach my pushing but I have never been very receptive to coaching and I ignored them and listened to my body. I pushed for half and hour and the baby crowned and retracted a couple times before I got him out but I think it was a good thing I didn’t push like I was told and pushed like I felt instead.